The importance of post-partum family planning.

Abstract

The increase in caesarean section rates led the World Health Organization (WHO) to review the guidance from 1985 which stated that there is no justification for any region to have a rate higher than 10–15%. The WHO statement on caesarean section rates from 2015 highlights that caesarean sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons; that at population level, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates; and that the effects of caesarean section rates on other outcomes, such as maternal and perinatal morbidity, paediatric outcomes, and psychological or social well-being, are still unclear and more research is needed to understand the health effects of caesarean section on immediate and future outcomes.1 In addition, caesarean sections that are medically unjustified increase health care costs unnecessarily. In this issue of Public Health Action, van den Boogaard et al. do not report on the overall caesarean rate in the district, instead focusing on the 2-year post-caesarean section outcomes for both the mothers and children, and in particular on family planning adherence and the inter-pregnancy interval.2 Reasons mentioned for non-initiation of, low acceptance of and low adherence to family planning after a caesarean section are religion and partner's consensus. Other factors that could play a role are education level, as women with higher education levels are more likely to better conceptualise the benefits of child spacing and are more likely to negotiate contraceptive use with their partners, rumours and misinformation about contraception side effects, taboos in the community, and financial or opportunity costs. Globally, 225 million women have an unmet need for family planning, resulting in 54 million unintended pregnancies, 16 million unsafe abortions and 79 000 maternal deaths annually.3 The promotion of family planning in countries with high birth rates has the potential to avert 32% of all maternal deaths and nearly 10% of childhood deaths.4 Effective use of post-partum and post-abortion family planning is an obvious way in which progress towards this goal could be achieved. Possible ways to strengthen family planning programmes is to have multiple programme elements linking demand with supply interventions, such as mass media and interpersonal communication approaches, male involvement, contracting with the private sector to expand service and product availability, and incentives such as conditional cash transfers that encourage patients to make decisions that lead to better health and motivate providers to exert the efforts necessary to deliver quality care. Political commitment is crucial as well. To help improve the quality of family planning programmes, the WHO updated the medical eligibility criteria for contraceptive use in 2015.5 One limitation mentioned in the study is the loss to follow-up of 20% of mothers, assumed to be due to giving an incorrect address. This could indicate that their children's birth was not registered and that they would thus miss out on the benefits of registration, and it highlights the need to strengthen civil registration and vital statistics systems worldwide. Finally, causes and solutions to health problems are often multisectoral in nature, and this is underscored by the global strategy for women's, children's and adolescents' health (2016–2030),6 which provides a road-map for collective action to advance the health and well-being of women, children and adolescents, and which will be central to achieving the United Nations' Sustainable Development Goals.7